allopurinol in chronic gout

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Allopurinol is the most widely prescribed drug for gout prophylaxis in the UK.

  • alopurinol is especially useful for patients with renal impairment or urate stones, in whom uricosuric drugs cannot be used
  • should be started at a low dose (e.g. 100mg per day or lower if there is renal impairment) taken after food
    • dose of allopurinol should then be increased gradually according to serum uric acid concentration (see linked item)
    • most common dose in UK is 300mg per day (1,2)
    • maximum dose is 900mg per day (3)

Notes:

  • initiation of prophylactic therapy may provoke an acute gout attack and so an NSAID or colchicine should be given concomitantly for at least the first 3 months
    • regarding colchicine:
      • there is evidence that patients starting allopurinol for crystal-proven chronic gouty arthritis while receiving colchicine 0.6 mg po bd reduces the frequency and severity of acute flares, and reduces the likelihood of recurrent flares. Treating patients with colchicine during initiation of allopurinol therapy for 6 months is supported (2)
  • prophylactic therapy should not be started during an acute attack because it can prolong symptoms
  • if an acute attack occurs during prophylactic treatment, this should be continued at the same dose while the acute attack is treated with an NSAID or colchicine
  • maximum dose of allopurinol (3)
    • maximum dose of allopurinol in the UK is 900 mg daily. However, the maximum permitted dose of allopurinol is lower in the presence of impaired renal function, determined by the degree of impairment. In severe renal failure, allopurinol should be commenced at the lower dose of 50 mg daily and increased in 50 mg increments. ULT is usually considered to be lifelong. Serum urate levels should be checked annually once target levels have been achieved
  • comparing allopurinol and febuxostat (4):
    • allopurinol and febuxostat achieved serum urate goals in patients with gout; allopurinol was noninferior to febuxostat in controlling flares. Similar outcomes were noted in participants with stage 3 chronic kidney disease

The summary of product characteristics must be consulted before prescribing this drug.

Reference:

  1. Drug and Therapeutics Bulletin (2004); 42(5):37-40.
  2. Borstad GC et al. Colchicine for prophylaxis of acute flares when initiating allopurinol for chronic gouty arthritis. J. Rhuematol 2004;31:2429-32.
  3. Arthritis Research UK (2011). Hands On (9) - gout: presentation and management in primary care.
  4. O'Dell JR et al.Comparative Effectiveness of Allopurinol and Febuxostat in Gout Management NEJM Evid 2022; 1 (3) DOI:https://doi.org/10.1056/EVIDoa2100028

Last edited 02/2022 and last reviewed 03/2022

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